Impact of Lactate on 30-Day All-Cause Mortality in Patients with and without Out-of-Hospital Cardiac Arrest Due to Cardiogenic Shock

Influence of Right and Left Bundle Branch Block in Patients With Cardiogenic Shock and Cardiac Arrest

OBJECTIVES

The study investigates the prognostic impact of right bundle branch block (RBBB) and left bundle branch block (LBBB) in patients with cardiogenic shock (CS) compared with no bundle branch block (BBB). In patients with heart failure, existence of RBBB and LBBB has influence on prognosis.

DESIGN

Prospective registry-study.

SETTING

ICU of a tertiary academic hospital in Germany.

PATIENTS

Adult patients with CS.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Consecutive patients with CS were included. The prognostic impact of RBBB and LBBB on 30-day all-cause mortality was tested within the entire cohort and in the subgroup of CS patients with cardiac arrest at admission. The final study cohort comprised 248 patients. Patients with RBBB showed the highest 30-day all-cause mortality followed by LBBB and no BBB (72.5% vs. 52.9% vs. 50.0%; log-rank p = 0.015). These findings were consistent even after solely including CS patients with cardiac arrest (90.0% vs. 73.3% vs. 62.2%; log-rank p = 0.008). After adjustment for lactate, norepinephrine, troponin I, Acute Physiology Score, Society of Cardiovascular Angiography & Interventions shock stage, and heart rate in a multivariable Cox regression analysis, RBBB still revealed a negative impact on 30-day all-cause mortality (hazard ratio [HR], 1.807; 95% CI, 1.107-2.947; p = 0.018), whereas LBBB was not associated with 30-day all-cause mortality. In this multivariable Cox regression model lactate (HR, 1.065; 95% CI, 1.018-1.115; p = 0.006), troponin I (HR, 1.003; 95% CI, 1.001-1.005; p = 0.001), and Acute Physiology Score (HR, 1.033; 95% CI, 1.001-1.066; p = 0.041) were as well associated with 30-day all-cause mortality. Finally, no association of RBBB was found with the incidence of liver or severe renal failure.

CONCLUSIONS

Besides the Acute Physiology Score, lactate, and troponin levels, RBBB was associated with an increased 30-day all-cause mortality in consecutive CS patients with and without cardiac arrest, whereas LBBB showed no prognostic impact.

Lactate-to-albumin ratio and cholesterol levels predict neurological outcome in cardiac arrest survivors

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) increases lactate levels and reduces albumin levels on admission and tends to lead to a poor neurological prognosis. In our experience, reduced cholesterol levels predict poor neurological prognosis. However, the relationship between cholesterol levels and neurological prognosis in OHCA survivors remains unclear.

METHODS

This retrospective observational study included data from January 2015 to June 2023 on 219 OHCA survivors at our intensive care unit. Patients were categorized into two groups based on cerebral functional classification (CPC) scores: Group A (CPC score of 1 or 2), including patients with a favorable neurological outcome, and Group B (CPC scores of 3 to 5), comprising those with a poor neurological outcome. We analyzed their lactate, albumin levels, and lipid profiles measured at 6 h after resuscitation. A model to predict the neurological prognosis of admission of OHCA survivors was developed.

RESULTS

Approximately 40% of the patients had favorable neurological outcomes at the 30-day follow-up. The lactate-to-albumin ratio (LAR) was significantly lower in Group A than in Group B (3.1 vs. 5.0 mmol/dag, p < 0.001). However, the albumin, total cholesterol, and high-density lipoprotein (HDL) cholesterol levels were significantly higher in Group A than in Group B (3.6 vs. 2.9 g/dL, 166.1 vs. 131.4 mg/dL, and 38.8 vs. 29.7 mg/dL, respectively, p < 0.001). Favorable neurological outcome was indicated at the following thresholds: LAR < 3.7 mmol/dag, albumin level > 3.1 g/dL, total cholesterol level > 146.4 mg/dL, and HDL-cholesterol level > 31.9 mg/dL. These findings underscore the high sensitivity and negative predictive value of the biomarkers. Furthermore, the area under the curve values for LAR, albumin, total cholesterol, and HDL-cholesterol levels were 0.70, 0.75, 0.71, and 0.71, respectively. The corresponding odds ratios were 3.37, 7.08, 3.67, and 3.94, respectively.

CONCLUSIONS

The LAR, albumin, total cholesterol, and HDL-cholesterol levels measured on admission may predict neurological prognosis in OHCA survivors. Thus, routine practice should include the measurement of these biomarkers at 6 h after resuscitation, especially in patients with a lactate level of > 5 mmol/L.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02633358.

Serum Lactate Is an Indicator for Short-Term and Long-Term Mortality in Patients with Acute Pancreatitis

BACKGROUND

Serum lactate, as a single and an easily available biomarker, has been applied in various diseases.

AIMS

In this study, we aimed to explore the predictive value of serum lactate for short-term and long-term prognosis in acute pancreatitis (AP) admitted in intensive care unit (ICU) based on a large-scale database.

METHODS

AP patients admitted in ICU in the MIMIC-IV database were included. We constructed three different models to investigate the relationships between serum lactate and clinical outcomes, including 30-day, 180-day and 1-year mortality in AP. Smooth fitting curves were performed for intuitively demonstrating the relationship between serum lactate and different outcomes in AP by the generalized additive model.

RESULTS

A total of 895 AP patients admitted in ICU were included. The mortalities of 30 days, 180 days, and 1 year were 12.63% (n = 113), 16.87% (n = 151), and 17.54% (n = 157). In model B, with 1-mmol/L increment in serum lactate, the values of OR in 30-day, 180-day and 1-year mortality were 1.20 (95%CI 1.04-1.37, P = 0.0094), 1.21 (95%CI 1.06-1.37, P = 0.0039), and 1.21 (95%CI 1.07-1.38, P = 0.0035). The AUCs of serum lactate for predicting 30-day, 180-day, and 1-year mortality in AP were 0.688 (95%CI 0.633-0.743), 0.655 (95%CI 0.605-0.705), and 0.653 (95%CI 0.603-0.701), respectively. The cut-off value of serum lactate predicting 30-day, 180-day and 1-year mortality in AP was 2.4 mmol/L.

CONCLUSION

Serum lactate could be an indicator for short-term and long-term mortality in patients with AP admitted in ICU.

Lactate Levels and Clearance: Key Predictors of Prognosis for COVID-19 and Non-COVID-19 Septic Shock Patients in the Emergency Department

BACKGROUND

This investigation assesses the prognostic value of lactate levels and their clearance in septic shock patients, particularly emphasizing the comparative analysis between COVID-19 and non-COVID-19 patients in the emergency department. This study aims to elucidate the unique prognostic implications of lactate dynamics in these distinct patient groups, thereby enhancing the management of septic shock.

METHODS

An observational prospective study was conducted, enrolling 114 septic shock patients from the Emergency County Hospital Resita, Romania, categorizing them into COVID-19 and non-COVID-19 groups to examine their initial lactate levels, clearance rates, and their correlation with patient outcomes.

RESULTS

This study identified significant differences in the initial lactate levels and clearance rates between the two groups, indicating higher initial lactate levels and slower clearance rates in COVID-19 patients. Survivors demonstrated significantly lower initial lactate levels (1.5 ± 0.4 mmol/L) and higher lactate clearance rates (33 ± 15%) compared to non-survivors (2.5 ± 0.5 mmol/L and 24 ± 9%, respectively; lactate levels p = 0.001, clearance rates p = 0.002).

CONCLUSIONS

Lactate monitoring, particularly clearance rates, is crucial in the prognostic assessment of septic shock patients. These findings highlight the need for targeted interventions in COVID-19 patients to improve outcomes, underscoring lactate dynamics as a vital component of septic shock management in differing patient populations.

Prognosis of cardiogenic shock with and without acute myocardial infarction: results from a prospective, monocentric registry

OBJECTIVE

The study investigates the prognostic impact of cardiogenic shock (CS) stratified by the presence or absence of acute myocardial infarction (AMI).

BACKGROUND

Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients.

METHODS

Consecutive patients with CS from 2019 to 2021 were included monocentrically. The prognostic impact of CS related to AMI was compared to patients without AMI-related CS. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan-Meier analyses, multivariable Cox proportional regression analyses and propensity score matching.

RESULTS

273 CS patients were included (AMI-related CS: 49%; non-AMI-related CS: 51%). The risk of 30-day all-cause mortality was increased in patients with AMI-related CS (64% vs. 47%; HR = 1.653; 95% CI 1.199-2.281; p = 0.002), which was still observed after multivariable adjustment (HR = 1.696; 95% CI 1.153-2.494; p = 0.007). Even after propensity score matching (i.e., 87 matched pairs), AMI was still an independent predictor of 30-day mortality (HR = 1.524; 95% CI 1.020-2.276; p = 0.040). In contrast, non-ST-segment AMI (NSTEMI) and STEMI were associated with comparable prognosis (log-rank p = 0.528).

CONCLUSION

AMI-related CS was associated with increased 30-day all-cause mortality compared to patients with CS not related to AMI. In contrast, the prognosis of STEMI- and NSTEMI-CS patients was comparable.

Management of cardiogenic shock: a narrative review

Cardiogenic shock (CS) is characterized by low cardiac output and sustained tissue hypoperfusion that may result in end-organ dysfunction and death. CS is associated with high short-term mortality, and its management remains challenging despite recent advances in therapeutic options. Timely diagnosis and multidisciplinary team-based management have demonstrated favourable effects on outcomes. We aimed to review evidence-based practices for managing patients with ischemic and non-ischemic CS, detailing the multi-organ supports needed in this critically ill patient population.

DIFFERENCES IN MANAGEMENT AND PROGNOSTICATION OF CARDIOGENIC SHOCK PATIENTS IN THE PRESENCE AND ABSENCE OF OUT-OF-HOSPITAL CARDIAC ARREST

ABSTRACT

Background: The clinical spectrum of acute myocardial infarction complicated by cardiogenic shock (AMICS) varies. Out-of-hospital cardiac arrest (OHCA) can be the first sign of cardiac failure, whereas others present with various degrees of hemodynamic instability (non-OHCA). The aim of the present study was to explore differences in prehospital management and characteristics of survivors and nonsurvivors in AMICS patients with OHCA or non-OHCA. Methods: Data analysis was based on patient data from the RETROSHOCK cohort comprising consecutive AMICS patients admitted to two tertiary cardiac centers between 2010 and 2017. Results: 1,716 AMICS patients were included and 42% presented with OHCA. Mortality in OHCA patients was 47% versus 57% in the non-OHCA group. Almost all OHCA patients were intubated before admission (96%). In the non-OHCA group, prehospital intubation (25%) was associated with a better survival ( P < 0.001). Lactate level on admission demonstrated a linear relationship with mortality in OHCA patients. In non-OHCA, probability of death was higher for any given lactate level <12 mmol/L compared with OHCA. However, a lactate level >7 mmol/L in non-OHCA did not increase mortality odds any further. Conclusion: Mortality was almost doubled for any admission lactate level up to 7 mmol/L in non-OHCA patients. Above this level, mortality remained unchanged in non-OHCA patients but continued to increase in OHCA patients. Prehospital intubation was performed in almost all OHCA patients but only in one of four patients without OHCA. Early intubation in non-OHCA patients was associated with a better outcome.

Association between serum lactate, lactate clearance rate, and 30-day mortality among patients undergoing mechanical ventilation: A retrospective cohort study of MIMIC-III database

Serum lactate has been used as a prognostic indicator in intensive care unit patients, and however, the single lactate value may not be enough to reflect changes during illness conditions. Herein, this study aims to explore the association between serum lactate and lactate clearance rate and 30-day mortality in patients undergoing mechanical ventilation (MV). Demographic and clinical data of 2628 adults were extracted from the medical information mart for intensive care-III clinical database in this retrospective cohort study. The lactate clearance rate was calculated using the serum lactate at the beginning of MV (T0), and serum lactate at the12 hours after MV beginning (T1). Univariate and multivariate Cox regression analyses were used to screen covariates, and explore the association between serum lactate and lactate clearance rate and 30-day mortality. We also explored these associations in different T0 serum lactate level subgroups. The evaluation indexes were hazard ratios (HRs) and 95% CIs. In addition, receiver operator characteristic (ROC) curve with area under the curve (AUC) was used to reflect the predictive performance of serum lactate and lactate clearance rate on 30-day mortality. A total of 827 (31.47%) mechanically ventilated patients died within 30 days. After adjusting for covariates, elevated T0 (HR = 1.04, 95%CI: [1.02-1.07]) and T1 (HR = 1.07, 95%CI: [1.04-1.10]) serum lactate was both associated with an increased risk of 30-day mortality, while higher lactate clearance rate was negatively associated with the risk of 30-day mortality (HR = 0.64, 95%CI: [0.50-0.81]). Among patients with T0 lactate ≥2 mmol/L, T1 serum lactate ≥4 mmol/L was associated with an increased risk of 30-day mortality, while lactate clearance rate ≥50 was associated with a decreased risk (all P < .05). Moreover, T1 serum lactate had a potential predictive value on 30-day mortality with an AUC of 0.605. Serum lactate and lactate clearance rate were both associated with 30-day mortality in patients undergoing MV. Our results may provide some references for further studies to explore the roles of serum lactate and lactate clearance rate in prognoses of critical patients.

Does Atrial Fibrillation Deteriorate the Prognosis in Patients With Septic or Cardiogenic Shock?

Atrial fibrillation (AF) is associated with increased risk of mortality in various clinical conditions. However, the prognostic role of preexisting and new-onset AF in critically ill patients, such as patients with septic or cardiogenic shock remains unclear. This study investigates the prognostic impact of preexisting and new-onset AF on 30-day all-cause mortality in patients with septic or cardiogenic shock. Consecutive patients with sepsis, or septic or cardiogenic shock were enrolled in 2 prospective, monocentric registries from 2019 to 2021. Statistical analyses included Kaplan-Meier, multivariable logistic, and Cox proportional regression analyses. In total, 644 patients were included (cardiogenic shock: n = 273; sepsis/septic shock: n = 361). The prevalence of AF was 41% (29% with preexisting AF, 12% with new-onset AF). Within the entire study cohort, neither preexisting AF (log-rank p = 0.542; hazard ratio [HR] 1.075, 95% confidence interval [CI] 0.848 to 1.363, p = 0.551) nor new-onset AF (log-rank p = 0.782, HR = 0.957, 95% CI 0.683 to 1.340, p = 0.797) were associated with 30-day all-cause mortality compared with non-AF. In patients with AF, ventricular rates >120 beats/min compared with ≤120 beats/min were shown to increase the risk of reaching the primary end point in AF patients with cardiogenic shock (log-rank p = 0.006, HR 1.886, 95% CI 1.164 to 3.057, p = 0.010). Furthermore, logistic regression analyses suggested increased age was the only predictor of new-onset AF (odds ratio 1.042, 95% CI 1.018 to 1.066, p = 0.001). In conclusion, neither the presence of preexisting AF nor the occurrence of new-onset AF was associated with the risk of 30-day all-cause mortality in consecutive patients admitted with cardiogenic shock.

The prothrombin time/international normalized ratio predicts prognosis in cardiogenic shock

OBJECTIVE

The study investigates the prognostic impact of the prothrombin time/international normalized ratio (PT/INR) in patients with cardiogenic shock.

BACKGROUND

Despite ongoing improvements regarding the treatment of cardiogenic shock patients, intensive care unit (ICU)-related mortality in cardiogenic shock patients remains unacceptably high. Limited data regarding the prognostic value of the PT/INR during the course of cardiogenic shock treatment is available.

METHODS

All consecutive patients with cardiogenic shock from 2019 to 2021 were included at one institution. Laboratory values were collected from the day of disease onset (day 1) and days 2, 3, 4 and 8. The prognostic impact of the PT/INR was tested for 30-day all-cause mortality, as well as the prognostic role of PT/INR changes during course of ICU hospitalization. Statistical analyses included univariable t -test, Spearman's correlation, Kaplan-Meier analyses, C-Statistics and Cox proportional regression analyses.

RESULTS

Two hundred twenty-four cardiogenic shock patients were included with a rate of all-cause mortality at 30 days of 52%. The median PT/INR on day 1 was 1.17. The PT/INR on day 1 was able to discriminate 30-day all-cause mortality in cardiogenic shock patients [area under the curve 0.618; 95% confidence interval (CI), 0.544-0.692; P  = 0.002). Patients with PT/INR > 1.17 were associated with an increased risk of 30-day mortality [62% vs. 44%; hazard ratio (HR) = 1.692; 95% CI, 1.174-2.438; P  = 0.005], which was still evident after multivariable adjustment (HR = 1.551; 95% CI, 1.043-2.305; P  = 0.030). Furthermore, especially patients with an increment of the PT/INR by ≥10% from day 1 to day 2 were associated with an increased risk of 30-day all-cause mortality (64% vs. 42%; log-rank P  = 0.014; HR = 1.833; 95% CI, 1.106-3.038; P  = 0.019).

CONCLUSION

Baseline PT/INR and an increase of the PT/INR during the course of ICU treatment were associated with the risk of 30-day all-cause mortality in cardiogenic shock patients.

Cardiac Troponin I but Not N-Terminal Pro-B-Type Natriuretic Peptide Predicts Outcomes in Cardiogenic Shock

This study investigates the prognostic value of cardiac troponin I (cTNI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in patients with cardiogenic shock (CS). Data regarding the prognostic value of cardiac biomarkers in CS is scarce, furthermore, most studies were restricted to CS patients with acute myocardial infarction (AMI). Therefore, consecutive patients with CS from 2019 to 2021 were included. Blood samples were retrieved from day of disease onset (day 1) and on days 2, 3 and 4 thereafter. The prognostic value of cTNI and NT-proBNP levels was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, Kaplan-Meier analyses and multivariable Cox proportional regression analyses. A total of 217 CS patients were included with an overall rate of all-cause mortality of 56% at 30 days. CTNI was able to discriminate 30-day non-survivors (area under the curve (AUC) = 0.669; p = 0.001), whereas NT-proBNP (AUC = 0.585; p = 0.152) was not. The risk of 30-day all-cause mortality was higher in patients with cTNI levels above the median (70% vs. 43%; log rank p = 0.001; HR = 2.175; 95% CI 1.510-3.132; p = 0.001), which was observed both in patients with (71% vs. 49%; log rank p = 0.012) and without AMI-related CS (69% vs. 40%; log rank p = 0.005). The prognostic impact of cTNI was confirmed after multivariable adjustment (HR = 1.915; 95% CI 1.298-2.824; p = 0.001). In conclusion, cTNI-but not NT-proBNP-levels discriminated 30-day all-cause mortality in CS patients.

Does Albumin Predict the Risk of Mortality in Patients with Cardiogenic Shock?

This study investigates the prognostic impact of albumin levels in patients with cardiogenic shock (CS). Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients. Limited data regarding the prognostic value of albumin in patients with CS is available. All consecutive patients with CS from 2019 to 2021 were included at one institution. Laboratory values were retrieved from the day of disease onset (day 1) and days 2, 3, 4, and 8 thereafter. The prognostic impact of albumin was tested for 30-day all-cause mortality. Moreover, the prognostic performance of albumin decline during ICU treatment was examined. Statistical analyses included univariable t-test, Spearman's correlation, Kaplan-Meier analyses, multivariable mixed analysis of variance (ANOVA), C-Statistics, and Cox proportional regression analyses. In total, 230 CS patients were included, with an overall all-cause mortality at 30 days of 54%. The median albumin on day 1 was 30.0 g/L. Albumin on day 1 was able to discriminate between 30-day survivors and non-survivors (area under the curve (AUC) 0.607; 0.535-0.680; p = 0.005). CS patients with albumin < 30.0 g/L were associated with an increased risk of 30-day all-cause mortality (63% vs. 46%; log-rank p = 0.016; HR = 1.517; 95% CI 1.063-2.164; p = 0.021), which was demonstrated even after multivariable adjustment. Moreover, a decrease of albumin levels by ≥20% from day 1 to day 3 was accompanied by a higher risk of 30-days all-cause mortality (56% vs. 39%; log-rank p = 0.036; HR = 1.645; 95% CI 1.014-2.669; p = 0.044). Especially when combined with lactate, creatinine, and cardiac troponin I, reliable discrimination of 30-day all-cause mortality was observed, including albumin in CS risk stratification models (AUC = 0.745; 95% CI 0.677-0.814; p = 0.001). In conclusion, low baseline albumin levels as well as a decay of albumin levels during the course of ICU treatment, deteriorate prognostic outcomes in CS patients. The additional assessment of albumin levels may further improve risk stratification in CS patients.

Norepinephrine dose, lactate or heart rate: what impacts prognosis in sepsis and septic shock? Results from a prospective, monocentric registry

OBJECTIVE

The study comprehensively investigates the prognostic value of norepinephrine (NE) dose, lactate and heart rate in patients with sepsis and septic shock.

BACKGROUND

Limited data regarding the prognostic value of NE dose, lactate and heart rate in patients meeting the sepsis-3 criteria is available.

METHODS

Consecutive patients with sepsis and septic shock from 2019 to 2021 were included. The prognostic value of NE dose, lactate and heart rate was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, C-statistics, Kaplan-Meier analyses, as well as one-factorial repeated measures analysis of variance (ANOVA) and Cox proportional regression analyses.

RESULTS

339 patients with sepsis or septic shock were included. With an area under the curve (AUC) of up to 0.638 and 0.685, NE dose and lactate revealed moderate prognostic accuracy for 30-day all-cause mortality, whereas heart rate was not associated with prognosis. Very high NE doses (i.e. > 1.0 mcg/kg/min) (HR = 2.938; 95% CI 1.933 - 4.464; p = .001) and lactate levels (i.e. ≥ 4 mmol/l) (HR = 2.963; 95% CI 2.095 - 4.191; p = .001) on admission were associated with highest risk of death. Finally, increasing NE doses and lactate levels from day 1 to 3 indicated increased risk of death, which was consistent after multivariable adjustment.

CONCLUSION

Both very high NE doses and lactate levels - but not heart rate - were associated with increased risk of 30-d all-cause mortality in patients with sepsis and septic shock.